SLR - October 2018 - Mahsa AghaJafarim

Foot Reconstruction Using a Free Proximal Peroneal Artery Perforator Flap: Anatomical Study and Clinical Application

Reference: Han HH, Lee YJ, Moon SH. Foot Reconstruction Using a Free Proximal Peroneal Artery Perforator Flap: Anatomical Study and Clinical Application. J Plast Reconstr Aesthet Surg. 2018;71(6):883–888.

Scientific Literature Review

Reviewed By: Mahsa AghaJafari
Residency Program: Maricopa Medical Center, Phoenix, AZ

Podiatric Relevance: Wound care is one of the main areas of focus in podiatric practice. Podiatrists evaluate patients with wounds due to diabetic ulcers, vascular disease, burns or trauma. For certain wounds, primary closure may be difficult, and grafts may be needed to assist in closure of defects. In certain areas, such as the dorsum of the foot, when a small and thin yet durable flap is needed for grafting and closure, proximal peroneal artery perforator may be a good option.

Methods: Retrospective chart review of 25 patients who underwent foot defect reconstruction using 27 proximal peroneal artery perforator flaps from January 2013 to December 2016. For retrieval of the flap, perforator position was marked at the proximal fibula using handheld doppler and angiographic CT. Once the flap was identified, it was elevated until sufficient pedicle length was achieved, and circulation was reexamined using handheld doppler. The artery and vein of the flap underwent end-to-end anastomosis with artery and vein in the area of defect, such as the first dorsal metatarsal artery and superficial dorsal vein for a forefoot defect. All patients underwent primary closure of site.

Results: Among 27 flaps, 24 had PPAP flaps in 22 patients. Average perforator location was 11.4 cm distal to the fibular head. Recipient vessels were mainly first dorsal metatarsal artery. Four vessel grafts were performed from the superficial dorsal vein. Of 24 flaps, 23 flaps had survived with average follow-up of 13 months. One flap had necrosis one week after percutaneous angioplasty. Two cases had wound disruption, which healed by secondary intention. Three cases had transient sensory loss associated with superficial peroneal nerve. All patients were able to wear shoes four weeks after procedures.

Conclusion: Foot defect reconstruction may be challenging and a durable thin tissue may be needed for good results. Using bulky tissue for transfer and wound closure may lead to secondary wounds due to walking on pressure and due to friction and sheer in footwear. Proximal peroneal perforating artery flap is a good option as it is the thinnest flap available but similar in thickness to the skin of the foot and it is relatively easy to elevate. The flap uses small vessel recipients that can be isolated around the wound; therefore, a long pedicle is not needed, and foot reconstruction can be done without sacrificing the source vessels. However, a complication with retrieval of PPAP may be injury to the superficial peroneal nerve, which is located approximately 3 cm posterior to the fibular head. Overall, due to properties previously mentioned, PPAP is a good flap to use in foot reconstruction and defect closure. 

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